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Number of glaucoma procedures in US decreases despite aging population
The total number of glaucoma surgical and laser procedures decreased among Medicare beneficiaries from 1994 to 2012.
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As the aging population grows in the U.S., the number of Medicare beneficiaries has increased but the number of glaucoma procedures has declined, according to a study.
“The main message is that the landscape of glaucoma surgery is changing,” study author Pradeep Y. Ramulu, MD, PhD, told Ocular Surgery News. “Before, trabeculectomy was, far and away, the primary surgery for glaucoma. Now, there are more cyclophotocoagulations performed than primary trabeculectomies, and most of these are done endoscopically. Also, it is interesting to see that several minimally invasive glaucoma procedures, such as endoscopic cyclophotocoagulation and canaloplasty in particular, are becoming more and more common.”
Examination of trends
The retrospective, observational analysis looked at Medicare fee-for-service paid claims data from 1994 to 2012 to determine the number and type of glaucoma-related procedures performed.
The total number of glaucoma surgical and laser procedures decreased 42% from 333,898 in 1994 to 193,552 in 2001. From 2001 to 2005, glaucoma-related procedures increased 66% from 193,552 to 321,680, but decreased again from 2005 to 2012 by 12% from 321,680 to 282,178.
From 1994 to 2003, the total number of glaucoma procedures declined 14% and continued to decrease another 2% from 2003 to 2012.
The total number of incisional glaucoma procedures declined 40% from 84,742 in 1994 to 50,514 in 2001, but has been relatively stable since, the study said. From 1994 to 2003, the number of incisional glaucoma procedures declined 28% and further decreased 3% from 2003 to 2012.
Individual procedures
Canaloplasty, mini shunts with an external approach, implantation of aqueous shunts in the extraocular reservoir and endoscopic cyclophotocoagulation (ECP) significantly increased in volume among Medicare Part B beneficiaries, while conventional trabeculectomy and transscleral cyclophotocoagulation significantly decreased.
“We expected to see a continued increase in ECP, but the magnitude of this increase was really surprising to us,” Ramulu said. “There are almost as many ECPs done as primary trabeculectomies. Likewise, it was interesting to see that one external mini-shunt (ie, the Ex-Press glaucoma filtration device, Alcon) was done for every three trabeculectomies.”
Laser trabeculoplasty procedures peaked in 2005 but steadily declined by 19% after that. The number of laser iridotomies was consistent over the last 8 years of the study.
Reasons for decrease not known
Despite a 9% increase in Medicare Part B beneficiaries, the total number of glaucoma procedures decreased 16% and the number of glaucoma procedures other than laser procedures decreased 31%.
“This is hard to explain given that there are more elderly and the age of Medicare recipients is increasing,” Ramulu said. “While we don’t know the specific reasons for this decrease, further study is needed to confirm whether this reflects less need for surgery or fewer persons getting surgery who need it.”
Because the study only determined the number of procedures, Ramulu and colleagues were unable to define the number of unique and repeat procedures as well as the number of new and returning patients.
“We only know the total volume of procedures done with these data and not who is doing the procedures and for what indications,” he said. “For example, we don’t know if ECP is done primarily for early disease at the time of cataract surgery or end-stage disease where other procedures have failed, though the high numbers suggest the former.”
With a movement from conventional trabeculectomy and trabeculoplasty toward IOP-lowering procedures, future trials comparing subsample data such as short- and long-term safety and efficacy, as well as cost-benefit ratio or the varying procedures, are recommended.
Additionally, with the release of Medicare data from individual doctors, it may be possible to determine if these newer procedures are done by a small set of selected physicians or widely done by a large number of practitioners, or if they are done by glaucoma specialists or general ophthalmologists, Ramulu said. – by Kristie L. Kahl
- Reference:
- Arora KS, et al. Ophthalmology. 2015;doi:10.1016/j.ophtha.2015.04.015.
- For more information:
- Pradeep Y. Ramulu, MD, PhD, can be reached at Johns Hopkins Hospital, 1800 Orleans St., Maumenee B-110, Baltimore, MD 21287; email: pramulu@jhmi.edu.
Disclosure: Ramulu reports no relevant financial disclosures.